SPECIAL CONSERVATION SCHEME LOAN

INTERIM APPLICATION

PLEASE REFER TO THE INFORMATION SHEET BEFORE COMPLETING THIS FORM

1.  NAME OF BORROWING ENTITY

Must be the same as the registered proprietor(s) of the land on which the works are to be carried out

Full Name(s) of Registered Proprietors / Position
(Director, Partner etc) / Date of Birth
ABN of the Borrowing Entity
Have you previously applied for assistance from the NSW Rural Assistance Authority? / YES / NO
If YES Quote reference number

2.  ADDRESS

Postal Address
Postcode
Telephone / Facsimile

3.  DETAILS OF THE PROPOSED WORKS

PURPOSE / ESTIMATED COST
$
$
$
$
TOTAL ESTIMATED COST / $
AMOUNT OF LOAN REQUIRED ( Maximum loan 90% of total estimated cost less GST ) / $

4.  DETAILS OF SECURITY OFFERED

Details of the Land on which the proposed works are to be carried out
Property Address
Total Area / Current Market Value / $ / Amount Owing / $

5.  ACKNOWLEDGEMENT

I/We acknowledge that this Interim application is submitted only to satisfy the requirement that before starting the above works, a formal application must be lodged.

I/We acknowledge that a decision will be dependent on the NSW Rural Assistance Authority receiving my/our formal application, my/our meeting all the eligibility criteria and, if required, appropriate technical standards as determined by other Government Agencies.

Applicant’s Signature / Date / Applicant’s Signature / Date

6.  STATEMENTS

GENERAL STATEMENT

Any person who knowingly and with intent to defraud the NSW Rural Assistance Authority or another person, files an application for assistance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime under the Crimes Act 1900 and subjects the person to criminal penalties.

PRIVACY

The information in this application is provided voluntarily and is being collected by the NSW Rural Assistance Authority for purposes related to the administration of the scheme of assistance under which you have applied, including the assessment of the effectiveness of the scheme. This may involve disclosing the information in this application to contractors engaged by the Authority or to either State or Commonwealth government agencies. We will supply you with details of those that we have disclosed information to, if you apply to us in writing. Information regarding your application may also be discussed and exchanged with the nominated contact persons listed by you in your application.

Not providing the information requested in this application or providing false or misleading or incomplete information may impact on the ability of the Authority to accurately assess your application.

The NSW Rural Assistance Authority agrees to take all reasonable measures to ensure that the personal information collected by it is stored securely.

You may access or correct your personal information by contacting the Authority by telephone on Toll Free 1800 678 593 (Calls to “1800” numbers from your home phone are free. Calls from a public phone and mobiles may be timed and attract charges.) or by writing to: Manager Administration, NSW Rural Assistance Authority, Locked Bag 23, ORANGE, NSW, 2800.

7.  LODGEMENT OF APPLICATIONS

Applications must be lodged directly to the Authority by any ONE of the following methods:

·  Post:

NSW Rural Assistance Authority

Locked Bag 23

ORANGE NSW 2800

·  Fax: 02 6391 3098

·  Email:

NSW Rural Assistance Authority Page 1 of 2 V: 3.2 08/12